I am a plastic surgeon in Little Rock, AR. I used to "suture for a living", I continue "to live to sew". These days most of my sewing is piecing quilts. I love the patterns and interplay of the fabric color. I would like to explore writing about medical/surgical topics as well as sewing/quilting topics. I will do my best to make sure both are represented accurately as I share with both colleagues and the general public.

Quilts of Valor

Followers

Wednesday, January 26, 2011

The question continues as to when breast screening should begin. The current pushback comes from radiologists Dr. Mark Helvie of the University of Michigan Health System and colleague Dr. Edward Hendrick of the University of Colorado.

The two researchers have published an article (full reference below) in the February issue of the American Journal of Roentgenology questioning the U.S. advisory panel’s breast cancer screening guidelines and suggesting the panel ignored scientific evidence that more frequent mammograms save lives.

For the article, the two conducted a review of the risk models used by the U.S. Preventive Services Task Force (USPSTF) to issue controversial breast screening guidelines in 2009. They used Cancer Intervention and SurveillanceModeling Network modeling to compare lives saved by differentscreening scenarios and the summary of evidence prepared forthe USPSTF to estimate the frequency of harms of screening mammographyby age.

The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. (Grade: C recommendation)

The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (Grade: I Statement)

The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. (Grade: I Statement)

The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. (Grade: I Statement)

Helvie and Hendrick analysis found that having annual mammograms from age 40 saved 64,889 more lives with the current 65%compliance rate.

They found that getting a yearly mammogram from age 40 cut a woman’s risk of fatal breast cancer by 71% versus the 23% reduction for women who followed the USPSTF recommendations.

The two researchers state, “The potential harms of a screening examinationin women 40–49 years old, on average, consist of the riskof a recall for diagnostic workup every 12 years, a negativebiopsy every 149 years, a missed breast cancer every 1,000 years, anda fatal radiation-induced breast cancer every 76,000–97,000years.”

The two researchers feel the advantages of yearly mammograms starting at age 40 years outweighs the potential harms of screening.

……..So, going back to the 10,000 women we are screening, of 9,900 who do NOT have cancer (remember that only 100 can have a true cancer), 10%, or 990 individuals, will still be diagnosed as having cancer. So, tallying up all of the positive mammograms, we are now faced with 1,070 women diagnosed with breast cancer. But of course, of these women only 80 actually have the cancer, so what's the deal? ……….

Unnecessary testing is bad. But the quote about medical decision making is so severely flawed in its description of how mammography works that it is misleading. To even compare a screening mammogram, a simple extremely low risk test designed to detect early breast cancer, to a non-indicated CT angiogram ordered in the ER is quite a stretch.

Mammography works by detecting small early stage cancers. In order to detect cancers when small and subtle additional imaging, and sometimes biopsy, is performed on a certain percentage of things that do not turn out to be cancers. If only obvious cancers are imaged and biopsied, and the smaller more subtle findings are ignored, the benefit of mammography is lost because obvious tumors are already large and higher stage and will carry a worse prognosis.

The idea of screening mammography is to find very early cancers that are likely to carry a favorable prognosis. This comes at the price of calling back about 10% of women for additional imaging. About 10% of these women (1% of those screened) will undergo biopsy. If you screen 1000 women, recall 100 women, and biopsy 10 women about 3-4 cancers will be diagnosed. The other women who get additional testing are not "diagnosed" with cancer as that quote states. Cancer is a pathologic diagnosis that requires biopsy and only 1% of women in screening will even undergo biopsy.

To better serve women's health we should be asking why fewer women are undergoing routine screening mammography today than 10 years ago. Compliance is down to 65%. I suspect misleading new reports which misinterpret extremely complex research are at least partly to blame as women are, understandably, quite confused right now.

In my opinion, the 2.5 million breast cancer survivors in the US right now, and the 260,000 who will be newly diagnosed this year alone, could use a break from all this nonsense.

Congratulations to Drs Hendrick and Helvie for their sane analysis of the USPSTF data. They are the people standing up against a tide of politics and misinformation in defense of a rational approach to women's health. Their work can ultimately save thousands of women's lives, if it is heeded.

Anon, I'm not sure where you got the "compare a screening mammogram, a simple extremely low risk test designed to detect early breast cancer, to a non-indicated CT angiogram ordered in the ER is quite a stretch." Did you read all of Dr. Zilberberg’s post? Women who have false positive mammograms "pay" for it in un-necessary surgery and other tests.

All medical testing comes at a cost. What is described as unecessary testing (additional imaging and biopsies on women who end up not having cancer) is an essential component of screening mammography.

A certain percentage of false positive cases are necessary to reduce the number of false negative cases (missed cancers). I tried to explain why in my previous comment.

In countries where mammography is practiced as advocated by the USPSTF cancers are detected by screening mammography when they are larger and less treatable. This is an effective method to reduce the cost of the test, in dollars and otherwise. Fewer women have the inconvenience of a call back or benign biopsy. But it isn't as effective at saving women's lives.

Ramona, thanks for this post. Such a complicated issue for patients and physicians

Since the recent USPSTF recommendations I have begun recommending "1-2" year followup for my lower risk women. But I wonder how I, or my patient, will feel about those recommendations if I ever find a cancer on screening mammography that would have had a betterr outcome on an annual schedule.

Health, but especially breast cancer, is a very emotional issue. When rational guidelines are applied, as I believe they should be, things get so very complicated.

Disclaimer

My purpose in writing my blog is to attempt to provide good solid medical information on topics of my choosing. It is a way to educate myself, my colleagues, and the general public. References will be provided on medical posts, but not on opinion essays or poetry posts. An additional purpose is to share my interest in quilting topics, a way to show my human side.

Any medical information provided by this site is not a replacement for medical diagnosis, treatment, or professional medical advice. It should not be used to treat or diagnose any medical condition. Always seek professional medical consultation by a licensed physician for diagnosis and treatment of any and all medical conditions - please, do not ignore your doctor's medical advice based on information written by the author or commenters of this site. Please do not ask me for medical advice, but instead contact a healthcare provider in your area. Anything written about office/hospital situations/events are fictional examples to get a point across. No patient is/will ever be a specific patient (unless given written permission), but a fictional one. To know more about how I handle medical information about patients please link here. Unless, I am praising a colleague, even those will be fictional. Any similarities to you or people you know is purely coincidental. My husband and I, and our dogs are fair game.

In early 2009 I joined the Better Health Network. As part of that Network, I will occasionally be paid for my writing. Those posts will be clearly noted. I will strive to maintain my high ethical standards. If I add any advertising, it will be clearly marked as such.

Privacy Principles

I do not intend to use this blog to collect or dispense private health information on patients. If any patient is used as an explicit example for a posting, I will get that patient's consent in writing to use their story and/or photo. The office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. However, that is not the intent of this blog. I intend to share information on medical/quilting topics with the general public and my colleagues. This web site does not share or sell any personal information, including your name, address, or email addresses with third parties. Have a blessed day!